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Based on observation, interview, record review, policy review and review of the United States Pharmacopoeia (USP) Chapter 797 the facility failed to:
- Ensure that the healthcare services were furnished in accordance with appropriate written policies that were consistent with applicable state law. (C271)
- Maintain and adhere to written policies and procedures. (C271)
- Ensure policies were reviewed at least annually by a group of professional personnel as designated. (C272)
- Ensure that staff followed the infection prevention standards for the USP for compounded sterile preparations. (C276)
- Have a quality control mechanism that demonstrated proper preparation and distribution of compounded sterile preparations (CSPs, medications or solutions that are prepared in a way to prevent contamination). (C276)
- Secure medications to prevent access from medication crash carts. (C276)
- Ensure that staff followed infection control policies and infection prevention standards. (C278)
- Have a mechanism in place to evaluate the effectiveness of the infection control policies and procedures and provide corrective action when necessary. (C278)

These deficient practices resulted in the facility's non-compliance with specific requirements found under 42 CFR 485.635 Condition of Participation: Provision of Services. The facility census was one.


Refer to the 2567 for additional information.








Refer to the 2567 for additional information.

Based on interview and policy review, the facility failed to maintain and adhere to written policies and procedures (a document that provides clear and standardized direction for personnel to follow in daily activities) addressing Abuse Prevention, Personnel, Nursing Services and Infection Control. These deficient practices had the potential to affect the safety and welfare of all patients receiving care at the facility. The facility census was one.

Findings included:

1. The facility failed to follow these policies:
- Policies and Procedures;
- Abuse Prohibition;
- Abuse Screening and Training Policy;
- Storage of Medications and Supplies;
- Cleaning and Inventory; and
- Handwashing Technique.

Review of the facility's policy titled, "Policies and Procedures," last revised 10/13/2014, showed direction to staff that existing facility polices shall be reviewed annually by Department Directors, Chief Nursing Officer, and the Chief Operating Officer.

During an interview on 06/12/19 at 4:00 PM, Staff A, Registered Nurse (RN), Director of Patient Care Services, stated that:
- Each department head is responsible for the review of their own policies.
- She had been in her current role for a year and a half.
- She had been asked to review her department policies, but told administration she would not sign them until she had read them.
- She was aware that numerous policies had not been reviewed

2. Review of the facility's policy titled, "Abuse Prohibition," revised 11/24/15, showed that potential staff members would have a criminal background check (CBC) and Employee Disqualification List (EDL, a listing of persons who had abused or neglected patients under their care) checked prior to employment.

Review of the facility's policy titled, "Abuse Screening and Training Policy," not dated, showed that:
- There should be a thorough screen of potential employees for any history of abuse, neglect, mistreatment of patients/residents, or misappropriation of patient/resident property.
- Any potential employee must consent to a CBC, and it should be completed within two days of employment.
- Verification upon hire that potential employees are not on the EDL list.

Review of the facility's personnel records showed that Staff N, Registered Nurse (RN) and Infection Control Manager, was hired on 08/29/11 and the facility failed to complete a background check upon hire.

Review of the facility's personnel records showed that Staff I, Registered Pharmacist, was hired on 05/09/19 and the facility failed to complete a CBC or an EDL verification.

Review of the facilities undated contracted staff list showed Staff Z, Occupational Therapist (OT), was hired on 02/14/09 and the facility failed to validate or complete a CBC or an EDL verification.

Review of the facilities undated contracted staff list showed Staff AA, Speech Therapist (ST), was hired on 07/01/15 and the facility failed to validate or complete a CBC or an EDL verification.

Review of the facilities undated contracted staff list showed Staff DD, Physical Therapist (PT), was hired on 06/03/13 and the facility failed to validate or complete a CBC or an EDL verification.

Review of the facilities undated contracted staff list showed Staff GG, Registered Dietician, was hired on 01/01/97 and the facility failed to validate or complete a CBC or an EDL verification.

During an interview on 06/11/19 at 10:00 AM, Staff W, Director of Human Resources, stated that:
- She was responsible to perform criminal background and EDL checks upon hire and periodic EDL checks post hire on all staff members.
- She did not include the contracted therapy staff members in her verification process and stated that she was not aware that she was supposed to be doing this.
- She stated that the non-therapy staff members that did not have a criminal background check or EDLs in place was missed as an oversight on her part.

During an interview on 06/12/19 at 4:00 PM, Staff A, Director of Nursing, stated that:
- Her expectation would be that all staff members, to include contracted staff, would have a criminal background screen and EDL verification completed prior to start of employment.
- She stated that she would expect a copy of the criminal background and EDL checks to be obtained from the contracting entity and placed into the facility employee file to ensure the safety and security of the patients.
- She had not been aware that this was not being completed on each individuals working at the hospital.

3. Review of the facility's policy titled "Storage of Medications and Supplied," approved 07/30/07, directed staff that all medications on the nursing units, except those requiring refrigeration, should be locked in the carts, and narcotics should be kept under double lock.

Observation on 06/10/19 at 3:35 PM, on the Acute Unit, showed a crash cart located behind the nursing desk without any type of barrier. The entire crash cart was not locked, all of the emergency medications and supplies, were easily accessible to any person able to pull open the drawer.

During an interview on 06/10/19 at 3:45 PM, Staff H, Registered Nurse (RN), stated that the top drawer of the crash cart on the Acute Unit, containing emergency medications, does not lock.

During an interview on 06/12/19 at 4:00PM, Staff A, Director of Patient Care Services, stated that all medications should be locked and secured, and that the rod on the ED crash cart should be solid enough to prevent anyone from opening the drawers.

4. Review of the facility's policy titled, "Cleaning and Inventory," revised 05/17/2017, showed that all supplies, drugs, and/or equipment is to be checked daily and replaced when necessary. All medications and supplies are to be checked weekly for any outdated items.

During an observation on 06/10/19 at 4:00 PM, in the Emergency Department, the following supplies were noted to be expired:
- Three arterial blood gas (ABG, the sampling of blood levels of oxygen and carbon dioxide within the arteries) kits expired on 07/2018.
- Seventeen pairs of sterile gloves, expired with numerous different dates.
- Multiple expired endotracheal tubes.

During an interview on 06/12/19 at 4:00 PM, Staff A, RN, Director of Patient Care Services, stated that any expired supplies should be removed, disposed of, and replaced routinely.

5. Review of the facility's policy titled, "Handwashing Technique," adopted 12/13/1996, showed that:
- The purpose of hand washing is to reduce contamination of hands which have come in contact with contaminated items, and to eliminate the spread of organisms to non-contaminated areas.
- Hands may be washed with soap and water, or by using alcohol hand sanitizers.
- Hands should be washed before patient contact, before a clean or aseptic task, after body fluid exposure, after patient contact, and after contact with the patient environment.

Review of the facility's policy titled, "Body Substance Precautions (BSP), "reviewed 09/2018, showed that the focus is on preventing potentially infectious substances off the hands of personnel through the use of gloves and hand washing. Hands should be washed prior to application of gloves, and after removal of gloves. Gloves should be changed between patients.

Observation on 06/11/19 at 11:18 AM, Staff M, Licensed Practical Nurse (LPN) failed to perform hand hygiene before putting on gloves and after removing gloves.

Observation on 06/12/19 at 11:40 AM, Staff U, LPN failed to perform hand hygiene before putting on gloves and after removing gloves.

During an interview on 06/11/19 at 4:15 PM, Staff N, RN, Infection Control and Quality, stated that her expectation would be for staff to perform hand hygiene before entering the room, before putting on gloves, before patient care, after patient care, after removing gloves, and before leaving the room. Staff should change gloves each time they go from a dirty task to a clean task.

During an interview on 06/12/19 at 4:00 PM, Staff A, RN, Director of Patient Care Services, stated that staff should follow all infection control policies, including proper hand hygiene. Before and after patient contact and application/removal of gloves.


39840




41865

Based on policy review and interview, the facility failed to maintain and review policies on an annual basis. This deficient practice had the potential to adversely affect all acute care and swing bed (Medicare program in which a patient can receive acute care, then if needed, Skilled Nursing care in the same facility) patients treated or admitted to the facility, by failing to direct appropriate care and services. The facility census was one.

Findings included:

1. Review of the facility's policy titled, "Policies and Procedures," last revised 10/13/2014, showed direction to staff that existing facility polices shall be reviewed annually by Department Directors, Chief Nursing Officer, and the Chief Operating Officer.

Review of the following facility policies showed that:
- "Policies and Procdures" was last revised on 10/13/14.
- "Cleaning and Inventory" was last revised on 05/17/17.
- "Patient Abuse and Neglect" was last revised on 11/24/15.
- "Abuse Screening and Training" showed no approval, revised or reviewed date.
- "Handwashing Technique" was adopted on 12/31/96 with no revised or reviewed date.
- "Intravenous Admixture Program" with approval date of 07/26/07.
- "Laminar Flow Hood" with approval date of 07/26/07.
- "Cleaning of the Pharmacy" with approval date of 07/26/07.
- "Intravenous Fluid Administration" with approval date of 07/26/07.
- "Removal of Drugs from the Pharmacy" with approval date of 07/26/07.
- "Storage of Medications and Supplies" with approval date of 07/30/07.
- "Admission of the Adult Patient" with approval date of 09/11/15.

During an interview on 06/12/19 at 4:00 PM, Staff A, Registered Nurse (RN), Director of Patient Care Services, stated that:
- She had been in her current role for a year and a half.
- She was aware that numerous policies had not been reviewed.
- Each department head is responsible for the review of their own policies.
- She had been asked to review her department policies, but told administration she would not sign them until she had read them.

During and interview on 06/11/19 at 10:45 AM, Staff I, Registered Pharmacist, stated that:
- She had been in her role for three weeks.
- She was aware that numerous changes would be required in the pharmacy.
- She had not reviewed all of the policies and procedures yet, but was aware that she needed to do that.


39840





41865

Based on observation, interview, policy review and review of the United States Pharmacopoeia (USP) Chapter 797 for compounded sterile preparations (CSPs, medications or solutions that are prepared in a way to prevent contamination), the facility failed to ensure that staff followed the facility's policy and the infection prevention standards when they failed to:
- Ensure the Segregated Compounding Area (SCA, designated space that is restricted for the preparation of CSPs) was kept uncluttered and free from paper products and particulates (very small particles, like dust, or similar).
- Document and clean the buffer area on days that medications were compounded.
- Have a documented proper garbing/procedure (shoe covers, hair and beard covers, mask, gown, gloves) to prevent contamination of the CSP.
- Have documented successful gloved fingertip testing (test to ensure staff who process CSPs were able to prevent contamination of the CSP) for staff members performing CSP.
- Have a quality control mechanism in place that demonstrates proper preparation and distribution of CSPs, as well as the ability to identify and react to any potential recall of the CSP.
- Secure medications to prevent access by unauthorized individuals from two medication crash carts (mobile cart which contains emergency medical supplies and medications) observed.

These failed practices had the potential to increase the risk of cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) and improper distribution in CSPs that may result in patient harm and/or death. The facility census was one.

Findings included:

1. Review of the USP, Chapter 797, dated 2008, showed that:
- Particle shedding objects (pencils, corrugated cardboard, paper, and cotton items) are prohibited in the buffer area.
- The buffer area floors should be cleaned daily, walls monthly, ceilings monthly, storage shelving monthly and documented on a cleaning log.
- Sampling plans that included surface disinfection sampling (growth media requirements) should be performed on a periodic basis, at a minimum, annually.
- Low risk compounding required a successful glove fingertip test prior to performing CSPs, and annually.

Review of the facility's policy titled, "Cleaning of the Pharmacy," dated 07/26/07 directed staff to:
- Perform daily dusting and routine cleaning of workbenches and furniture.
- Perform daily mopping of the floor.
- Dust storage shelves and drawers at frequent intervals.
- Keep the dispensing area uncluttered and clean at all times.
- Prepare all sterile preparations under the laminar flow hood (enclosed work bench which prevents contamination of medications when the medication is mixed or prepared).

Review of the facility's policy titled, "Laminar Flow Hood," dated 07/26/07 directed staff to:
- Wash hands or use hand sanitizer before and after working under the hood.
- Clean the inside of the hood every morning and every evening with alcohol.
- Remove any spills or splatters each time the hood was used.

Review of the facility's policy titled, "Intravenous (IV, in the vein) Admixture Program," dated 07/26/07 directed staff to:
- Always have two nurses present during mixing medications.
- Second nurse was to observe proper technique of adding medication.
- Second nurse was to cosign assuring proper medication was properly prepared.

Review of the facility's Pharmacy sign out sheet did not show a second nurse's signature.

Review of the facility's policy titled, "Storage of Medications and Supplies," dated 07/30/07 directed staff to store drugs within the pharmacy under the supervision of the pharmacy department under proper conditions of sanitation, temperature, light, moisture, ventilation, segregation, and security.

Review of the facility's policy titled, "Intravenous Fluid Administration," dated 07/26/07 directed staff to wash hands with an antiseptic before mixing solutions.

Observation on 06/11/19 at 10:06 AM in the pharmacy showed:
- Exposed paper on the walls and cabinets just outside the laminar flow hood;
- Cardboard boxes with torn edges on the supply shelves near the laminar flow hood;
- Wooden shelves with chipped paint near the laminar flow hood;
- Wooden containers on the countertop with partially removed tape with flaking present;
- Corkboard bulletin boards just outside the laminar flow hood;
- Dust on the cords of the laminar flow hood;
- Dust on the top of the laminar flow hood;
- Splashes of brown color on the walls outside the laminar flow hood;
- Ceiling tiles that were crumbling above the laminar flow hood;
- Black mold like substance on the return air vents directly across from the laminar flow hood;
- A sink with green corrosion located next to the laminar flow hood; and
- Dirt on the floor.

During an interview on 06/11/19 at 10:06 AM, Staff I, Pharmacist stated that:
- She had only worked there for the past three weeks.
- She was not sure what the Pharmacy 797 rules were for compounding in a hospital.
- There were no logs for cleaning in the pharmacy.
- She was not sure when the floors or walls had been cleaned.
- There were no logs for compounding medications in the pharmacy.
- The Director of Nursing provided education to the nurses about mixing medications.
- There was no inventory system for removal of drugs from the pharmacy, only a written log of what medications had been removed.
- The nurses were using exam gloves after washing their hands, prior to mixing medications.
- The nurses only wore gloves but no gown and no head cover when mixing medications.
- There were no records of fingertip testing of the nurses.

During an interview on 06/11/19 at 11:10 AM, Staff J, Registered Nurse (RN) stated that:
- She did not wear a mask, gown, or sterile gloves when working under the laminar flow hood.
- She mixed antibiotics and protonix (drug used to treat certain stomach problems).
- There was no documentation of mixing medicines, but two nurses signed off on the antibiotic mixtures.

During an interview on 06/11/19 at 2:29 PM, Staff R, RN stated that:
- She used clean gloves when mixing medications under the laminar flow hood.
- She did not wear a gown or head cover.
- She received some education upon hire from another nurse.
- She had never been fingertip tested.

During an interview on 06/11/19 at 2:47 PM, Staff S, RN stated that she had not received training or been fingertip tested.

During an interview on 06/11/19 at 4:15 PM, Staff L, Infection Control RN stated that:
- The previous pharmacist used to train staff on mixing medications.
- Staff had not been using sterile gloves when mixing medications under the laminar flow hood.
- There had been no fingertip testing for staff.

2. Review of the facility's policy titled, "Removal of Drugs from the Pharmacy," dated 07/26/07 directed staff to record the drug withdrawal made by a nurse in the notebook with the following details recorded:
- Drugs name,
- Drugs strength,
- Amount of the drug taken,
- The date,
- The patient's name, and
- The nurse's initials.

Review of the facility's Pharmacy sign out sheet failed to show documentation of the drug strength and the patient's name.

During an interview on 06/11/19 at 11:09 AM, Staff A, RN Director of Patient Services stated that she was not aware that more documentation was needed on the sign out sheet in the pharmacy.

3. Review of the facility's policy titled "Storage of Medications and Supplies," approved 07/30/07, directed staff that all medications on the nursing units, except those requiring refrigeration, should be locked in the carts, and narcotics should be kept under double lock.

Observation on 06/10/19 at 3:35 PM, on the Acute Unit, showed a crash cart located behind the nursing desk without any type of barrier. The entire crash cart was not locked, all of the emergency medications and supplies, were easily accessible to any person able to pull open the drawer.

Observation on 06/10/19 at 4:00 PM, in ED Area, showed a large open room with curtains separating each exam area or bay (a total of four bays). The crash cart located in Bay 1 had a thin, flat, flimsy rod, of approximately two centimeters in width, being used to secure the drawers. The rod was not snug against the drawers, there was a gap of about two inches, which allowed the drawers to be partially opened without unlocking the lock. The lack of sturdiness allowed easy access to medications, needles, and syringes, by any person able to pull the drawer open.

During an interview on 06/10/19 at 3:45 PM, Staff H, Registered Nurse (RN), stated that:
- The charge nurse for each shift carries keys to the pharmacy and the locks for narcotics and the crash cart.
- The top drawer of the crash cart on the Acute Unit doesn't lock.
- The top drawer is the drawer containing emergency medications.

During an interview on 06/12/19 at 4:00PM, Staff A, Director of Patient Care Services, stated that all medications should be locked and secured, and that the rod on the ED crash cart should be solid enough to prevent anyone from opening the drawers.




39147




41865

Based on observation, interview and policy review, the facility failed to ensure that staff maintained and followed infection control policies and infection prevention standards when they failed to:
- Have a mechanism in place to evaluate the effectiveness of the Infection Control Policy and provide corrective action when necessary.
- Perform hand hygiene (wash with soap and water or alcohol-based hand sanitizer) when indicated during patient care.
- Remove all particle shedding objects from pharmacy laminar air flow system.
- Provide barrier between construction area and patient rooms.
- Ensure items were packaged properly to maintain sterile conditions.
- Expired or opened supplies were not available for patient use.
- Appropriately store clean linen to minimize contamination.
- Maintain a policy to ensure the sterilization of endoscope (instrument used to examine the interior of a hollow organ or cavity of the body with a lighted tube with a camera) prior to and during procedures.
- Ensure that all patient food items were properly labeled and dated in the nourishment refrigerator.
- Maintain temperature log for nourishment refrigerator.

These failed practices had the potential to expose all patients, visitors and staff to cross contamination (germs that are spread from one person or surface to another), increase the risk for infection and foodborne illness. The facility census was one.

Findings included:

1. Review of the facility's policy titled, "Infection Control (IC) Program," reviewed 09/13/2018, showed that:
- The facility followed the recommended guidelines provided by the Centers for Disease Control (CDC).
- Policies and procedures developed in relation to infection control applied to all areas and departments of the hospital.
- The IC committee determined that two and one half hours per week would be adequate for the IC Nurse to perform surveillance and follow up on all observations and issues.
- The infection control program implemented would monitor the compliance and maintain a system for reporting and reviewing infections in patients and personnel.

During an interview on 06/11/19 at 4:15 PM, Staff N, RN, Infection Control and Quality, stated that:
- She really didn't have an Infection Control Program.
- She did not track and trend infections.

During an interview on 06/12/19 at 4:00 PM, Staff A, RN, Director of Patient Care Services, stated that:
- As part of the IC program, there should be audits/surveillance done on random basis in all areas of the hospital, including special attention to hand hygiene and medication passes.
- Two and a half hours allotted for the IC Nurse, was not enough time to properly monitor IC processes in the hospital.

2. Review of the facility's policy titled, "Cleaning and Inventory," revised 05/17/2017, showed that:
- All supplies, drugs, and/or equipment is to be checked daily and replaced when necessary.
- Medication and supply outdates are to be checked weekly.

During an observation on 06/10/19 at 3:35 PM, on Hall 100, Acute Care, the following were noted:
- Between room 107 and 109, the drywall had been removed, exposing the air conditioning unit, and two by four boards, creating a direct line of sight into room 107, where an entire wall had been removed; there was not barrier between this open area and the hallway.
- The only patient on the hall was directly across for this open area.
- A full linen cart was stored in room 112; the barrier/drape on the cart was not closed, leaving all the linens stored there exposed.
- In room 101, suction tubing was unwrapped and stored on top of the suction canister.
- Strips of disinfecting caps (a disposable cap used to disinfect a patient's intravenous [IV, in the vein] line injection ports) stored on IV poles in each four ED bays.

During an observation on 06/10/19 at 4:00 PM, in the Emergency Department, the following supplied were noted to be expired:
- Three arterial blood gas (ABG, the sampling of blood levels of oxygen and carbon dioxide within the arteries) kits expired on 07/2018.
- Two walls of supplies, such as oxygen tubing, endotracheal tubes, pediatric oxygen supplies, and IV tubing, the packages were pierced, and stored on peg boards.
- Seventeen pairs of sterile gloves, expired with numerous dates.
- Multiple expired endotracheal tubes.

During an interview on 06/12/19 at 4:00 PM, Staff A, RN, Director of Patient Care Services, stated that:
- The wall was currently being repaired, and that there should have been a barrier between the construction and the hall.
- Any expired supplies should be removed, disposed of, and replaced routinely.
- All tubing and supplies should remain in intact packages, holes in the packages should not happen.
- All supplies stored on the peg board should be in locked cabinets.
- Linen stored on carts should be covered, not left exposed.

During an interview on 06/11/19 at 4:15 PM, Staff N, RN, Infection Control and Quality, stated that her expectation would be that all expired supplies would be removed, and replaced.

Observation on 06/11/19 at 9:24 AM in the computed tomography (CT, a combination of X-rays and a computer to create pictures of your organs, bones, and other tissues, which shows more detail that a regular X-Ray) room showed an unpackaged oral airway in the emergency drug box.

Observation on 06/11/19 at 9:14 AM in the radiology room showed a suction canister with tubing and suction instrument connected.

During an interview on 06/11/19 at 9:24 AM, Staff L, Radiology Manager stated that the oral airway would be used if necessary.

During an interview on 06/11/19 at 4:15 PM, Staff N, RN, Infection Control and Quality stated that she would expect the oral airway to be packaged.

During an interview on 06/11/19 at 9:24 AM, Staff L, Radiology Manager stated that the suction was set up and ready to be used.

During an interview on 06/11/19 at 4:15 PM, Staff N, RN, Infection Control and Quality stated that suction tubing and suction instrument should be in the package.

Observation on 06/11/19 at 9:14 AM showed oxygen extension tubing connected to the oxygen flowmeter on three separate oxygen flowmeters in the radiology department with no date or time.

During an interview on 06/11/19 at 9:24 AM, Staff L, Radiology Manager stated that the extension tubing's were probably changed monthly and were not dated, they just connected the extension tubing to the patients' oxygen tubing.

During an interview on 06/11/19 at 4:15 PM, Staff N, RN, Infection Control and Quality stated that oxygen extension tubing should not be used for more than one patient.

Observation on 06/11/19 at 1:55 PM in the laboratory showed an area of floor covering measuring approximately three feet by five feet missing from the floor which revealed the concrete flooring and multiple large cracks in the flooring.

During an interview on 06/11/19 at 1:55 PM, Staff Q, Medical Laboratory Technician stated that she had worked there for nine months and the floor had always looked like that.

3. Review of the facility policy titled, "Handwashing Technique," dated 12/13/96 directed staff to perform hand hygiene by using alcohol hand sanitizer or soap and water before patient contact, before clean tasks, after patient contact, and after contact with the patients' environment.

Review of the facility's policy titled, "Body Substance Precautions (BSP)," reviewed 09/13/2018, directed staff to perform hand hygeine before glove application, after glove removal, and that gloves should be changed between patients.

Observation on 06/11/19 at 11:18 AM, Staff M, Licensed Practical Nurse (LPN) failed to perform hand hygiene before putting on gloves and after removing gloves.

Observation on 06/12/19 at 11:40 AM, Staff U, LPN failed to perform hand hygiene before putting on gloves and after removing gloves.

During an interview on 06/11/19 at 4:15 PM, Staff N, RN, Infection Control and Quality stated that hand hygiene should be performed before putting on gloves and after removing gloves. She had not provided an in-service on hand washing and staff were required to complete education on the computer

During an interview on 06/12/19 at 4:00 PM, Staff A, RN Director of Patient Services stated that she expected staff to perform hand hygiene before putting on gloves and after removing gloves.

4. Review of facility policies showed no policy for checking the food in the refrigerator at the nurse's station.

Observation on 06/12/19 at 11:25 AM in the refrigerator at the nurse's station showed four containers of red gelatin without a date or time.

During an interview on 06/12/19 at 4:00 PM, Staff A, RN Director of Patient Services stated that she would not expect to see undated food in the refrigerator.

5. Review of facility policies showed no policy for checking the temperature in the refrigerator at the nurse's station.

Observation on 06/12/19 at 11:25 AM showed inconsistent documentation of the refrigerator temperatures on the temperature logs.

During an interview on 06/12/19 at 4:00 PM, Staff A, RN Director of Patient Services stated that she expected the refrigerator temperature to be monitored and documented daily on the temperature log.

6. Review of the facility policies showed no policy for cleaning or disinfecting of endoscopes (instrument used to examine the interior of a hollow organ or cavity of the body with a lighted tube with a camera).

During an interview on 06/12/19 at 2:35 PM, Staff Y, LPN stated that:
- The physician brought the endoscope to the facility.
- She used a disinfectant wipe, which stated on the label that it was not to be used on an instrument that is introduced directly into the body, to clean the endoscope before she soaked it in the sterilization liquid and between patient use.
- She did not use any test strips to test the condition of the sterilization solution.
- She did not perform a test on the endoscope to see if it was leaking.
- She was not aware of any policy that addressed endoscope cleaning.

During an interview on 06/12/19 at 4:00 PM, Staff A, RN Director of Patient Services stated that:
- She would not expect a disinfectant wipe which was not approved for patient use to be used on an endoscope.
- She would expect the sterilization liquid to be tested.
- She would expect the endoscope to be checked for leaks.

During an interview on 06/12/19 at 4:00 PM, Staff A, RN, Director of Patient Care Services, stated that her expectation for staff would be for them to follow all Infection Control policies.





39840

Findings included:
ABObservation on 06/11/19 at 9:24 AM in the computed tomography (CT, a combination of X-rays and a computer to create pictures of your organs, bones, and other tissues, which shows more detail that a regular X-Ray) room showed an unpackaged oral airway in the emergency drug box.

ABDuring an interview on 06/11/19 at 9:24 AM, Staff L, Radiology Manager stated that the oral airway would be used if necessary.

ABDuring an interview on 06/11/19 at 4:15 PM, Staff N, Infection Control Registered Nurse (RN) stated that she would expect the oral airway to be packaged.


ABObservation on 06/11/19 at 9:14 AM in the radiology room showed a suction canister with tubing and suction instrument connected.

ABDuring an interview on 06/11/19 at 9:24 AM, Staff L, Radiology Manager stated that the suction was set up and ready to be used.

ABDuring an interview on 06/11/19 at 4:15 PM, Staff N, Infection Control RN stated that suction tubing and suction instrument should be in the package.


ABObservation on 06/11/19 at 9:14 AM showed oxygen extension tubing connected to the oxygen flowmeter on three separate oxygen flowmeters in the radiology department with no date or time.

ABDuring an interview on 06/11/19 at 9:24 AM, Staff L, Radiology Manager stated that the extension tubing's were probably changed monthly and were not dated, they just connected the extension tubing to the patients' oxygen tubing.

ABDuring an interview on 06/11/19 at 4:15 PM, Staff N, Infection Control RN stated that oxygen extension tubing should not be used for more than one patient.


ABReview of the facility policy titled, "Handwashing Technique," dated 12/13/96 directed staff to perform hand hygiene by using alcohol hand sanitizer or soap and water before patient contact, before clean tasks, after patient contact, and after contact with the patients' environment.

ABObservation on 06/11/19 at 11:18 AM, Staff M, Licensed Practical Nurse (LPN) failed to perform hand hygiene before putting on gloves and after removing gloves.

ABObservation on 06/12/19 at 11:40 AM, Staff U, LPN failed to perform hand hygiene before putting on gloves and after removing gloves.

ABDuring an interview on 06/11/19 at 4:15 PM, Staff N, Infection Control RN stated that hand hygiene should be performed before putting on gloves and after removing gloves.

ABDuring an interview on 06/12/19 at 4:00 PM, Staff A, RN Director of Patient Services stated that she expected staff to perform hand hygiene before putting on gloves and after removing gloves.



ABObservation on 06/11/19 at 1:55 PM in the laboratory showed an area of floor covering measuring approximately three feet by five feet missing from the floor which revealed the concrete flooring and multiple large cracks in the flooring.

ABDuring an interview on 06/11/19 at 1:55 PM, Staff Q, Medical Laboratory Technician stated that she had worked there for nine months and the floor had always looked like that.


ABReview of facility policies showed no policy for checking the food in the refrigerator at the nurse's station.

ABObservation on 06/12/19 at 11:25 AM in the refrigerator at the nurse's station showed four containers of red gelatin without a date or time.

ABDuring an interview on 06/12/19 at 4:00 PM, Staff A, RN Director of Patient Services stated that she would not expect to see undated food in the refrigerator.


ABReview of facility policies showed no policy for checking the temperature in the refrigerator at the nurse's station.

ABObservation on 06/12/19 at 11:25 AM showed inconsistent documentation of the refrigerator temperatures on the temperature logs.

ABDuring an interview on 06/12/19 at 4:00 PM, Staff A, RN Director of Patient Services stated that she expected the refrigerator temperature to be monitored and documented daily on the temperature log.


ABReview of the facility policies showed no policy for cleaning or disinfecting of endoscopes (instrument used to examine the interior of a hollow organ or cavity of the body with a lighted tube with a camera).

ABDuring an interview on 06/12/19 at 2:35 PM, Staff Y, LPN stated that:
- The physician brought the endoscope to the facility.
- She used a disinfectant wipe, which stated on the label that it was not to be used on an instrument that is introduced directly into the body, to clean the endoscope before she soaked it in the sterilization liquid and between patient use.
- She did not use any test strips to test the condition of the sterilization solution.
- She did not perform a test on the endoscope to see if it was leaking.
- She was not aware of any policy that addressed endoscope cleaning.

ABDuring an interview on 06/12/19 at 4:00 PM, Staff A, RN Director of Patient Services stated that:
- She would not expect a disinfectant wipe which was not approved for patient use to be used on an endoscope.
- She would expect the sterilization liquid to be tested.
- She would expect the endoscope to be checked for leaks.



41865

Based on observation, interview, record review and policy review, the facility failed to ensure Swing Bed (SB, a specific type of reimbursement for patients that need a skilled service, such as therapy, but do not need the level of care in a regular patient bed) patients received the following:
- A thorough, individualized, documented activity assessment for one current SB patient (#2) and six discharged SB patients (#4, #5, #6, #7, #8 and #9) of seven reviewed. This failed practice prevented meaningful activities, which enriched the patients' minds and bodies, from being offered and/or planned, and had the potential to affect all Swing Bed patients. (C385)
- A pertinent, individualized activities as determined via assessment of needs, interests and abilities for one current SB patient (#2) and six discharged SB patients (#4, #5, #6, #7, #8 and #9) of seven reviewed. This failed practice prevented all Swing Bed patients from receiving stimulating, meaningful, and pertinent activities that could improve their quality of life and improve overall health. (C385)
- A monthly activity calendar for one SB patient (#2) of one observed. This failed practice prevented the patient from being aware of available activities on a given day, and could affect all Swing Bed patients. (C385)
- Care performed by staff that were effectively screen prior to employment, and on a periodic basis after hire, by comparing the names of staff against the Employee Disqualification List (EDL, a listing of persons who had abused or neglected patients under their care) of one permanent employee (I) and eight contracted employees (Z, AA, BB, CC, DD, EE, FF and GG) of 16 employee records reviewed to ensure that any staff on the EDL list were not employed in the facility. (C381)
- Care performed by staff that had a complete a criminal background check (CBC) completed prior to first day of employment for 10 employees (I, N, Z, AA, BB, CC, DD, EE, FF and GG) of 16 employee records reviewed. (C381)

These deficient practices resulted in the facility's non-compliance with specific requirements found under the Condition of Participation: Swing Beds. The facility census was one SB patient.

Refer to the 2567 for additional information.

Based on Missouri State Statute review, policy review, staff record review, and interview, the facility failed to ensure the following:
- Effectively screen all staff prior to employment, and on a periodic basis after hire, by comparing the names of staff against the Employee Disqualification List (EDL, a listing of persons who had abused or neglected patients under their care) of one permanent staff (I) and eight contracted staff (Z, AA, BB, CC, DD, EE, FF and GG) of 16 staff records reviewed to ensure that any staff on the EDL list were not employed in the facility.
- A criminal background check (CBC) was completed within the first two days of employment for 10 staff (I, N, Z, AA, BB, CC, DD, EE, FF and GG) of 16 staff records reviewed.

This failure had the potential to place all patients admitted to the facility at risk for their safety from abuse and neglect by staff members. The facility census was one.

Findings included:

1. Review of RSMo 192.2495, showed that prior to allowing any person who has been hired full-time, part-time, temporary or through contract to have contact with any patient, a request would be made for a criminal background check as well as an inquiry made to the Department of Health and Senior Services, whether the person was listed on the EDL.

Review of the facility's policy titled, "Abuse Screening and Training Policy," revised 11/2015, showed that it is the policy of Sullivan County Memorial Hospital to thoroughly screen potential employees for a history of abuse, neglect, mistreatment of residents, or misappropriation of resident's property. Prior to an employee starting work at Sullivan County Memorial Hospital, a criminal background check will be obtained and a verification that the applicant is not on the EDL will be conducted. Upon employment periodic checks of the EDL will be conducted to ensure that the employee has not been added to the EDL.

Review of the facility's personnel records showed that Staff N, Registered Nurse (RN) and Infection Control Manager, was hired on 08/29/11 and the facility failed to complete a background check upon hire.

Review of the facility's personnel records showed that Staff I, Registered Pharmacist, was hired on 05/09/19 and the facility failed to complete a criminal background screen or an EDL verification.

Review of the facilities undated contracted staff list showed Staff Z, Occupational Therapist (OT), was hired on 02/14/09 and the facility failed to validate or complete a criminal background screen or an EDL verification.

Review of the facilities undated contracted staff list showed Staff AA, Speech Therapist (ST), was hired on 07/01/15 and the facility failed to validate or complete a criminal background screen or an EDL verification.

Review of the facilities undated contracted staff list showed Staff BB, Occupational Therapist (OT), was hired on 02/03/09 and the facility failed to validate or complete a criminal background screen or an EDL verification.

Review of the facilities undated contracted staff list showed Staff CC, Occupational Therapist (OT), was hired on 08/22/16 and the facility failed to validate or complete a criminal background screen or an EDL verification.

Review of the facilities undated contracted staff list showed Staff DD, Physical Therapist (PT), was hired on 06/03/13 and the facility failed to validate or complete a criminal background screen or an EDL verification.

Review of the facilities undated contracted staff list showed Staff EE, Physical Therapist (PT), was hired on 07/19/12 and the facility failed to validate or complete a criminal background screen or an EDL verification.

Review of the facilities undated contracted staff list showed Staff FF, Physical Therapist (PT), was hired on 11/28/16 and the facility failed to validate or complete a criminal background screen or an EDL verification.

Review of the facilities undated contracted staff list showed Staff GG, Registered Dietician, was hired on 01/01/97 and the facility failed to validate or complete a criminal background screen or an EDL verification.

During an interview on 06/11/19 at 10:00 AM, Staff W, Director of Human Resources, stated that she was responsible to perform criminal background and EDL checks upon hire and periodic EDL checks post hire on all staff members. She did not include the contracted therapy staff members in her verification process and stated that she was not aware that she was supposed to be doing this. She stated that the non-therapy staff members that did not have a criminal background check or EDLs in place was missed as an oversight on her part.

During an interview on 06/12/19 at 4:00 PM, Staff A, Director of Nursing, stated that it is her expectation that all staff members, to include contracted staff, would have a criminal background screen and EDL verification completed prior to start of employment. She stated that at minimum she would expect a copy of the criminal background screens and EDL checks to be obtained from the contracting entity and placed into the facility employee file to ensure the safety and security of the patients. She had not been aware that this was not being completed on each individual working at the hospital and she had not had direct oversight of this program. She shared that in the past there had been a Chief Nursing Officer (CNO) in place at the hospital, but that person had resigned over a year ago. She had assumed all the additional responsibilities of the former CNO and had since been working to prioritize her case load based on urgency and need.






40710

Based on observation, interview, record review and policy review the facility failed to:
- Conduct a thorough, individualized, documented activity assessment for one current Swing Bed (SB, Medicare program in which a patient can receive acute care, then if needed, Skilled Nursing care in the same facility) patient (#2) and six discharged SB patients (#4, #5, #6, #7, #8 and #9) of seven reviewed. This failed practice prevented meaningful activities, which enriched the patients' minds and bodies, from being offered and/or planned and had the potential to affect all SB patients.
- Provide pertinent, individualized activities as determined via assessment of needs, interests and abilities for one SB patient (#2) and six discharged SB patients (#4, #5, #6, #7, #8 and #9) of seven reviewed. This failed practice prevented all SB patients from receiving stimulating, meaningful, and pertinent activities that could improve their quality of life and improve overall health.
- Provide a monthly activity calendar, and provide activities for one SB patient (#2) of six reviewed. This failed practice prevented patient from being aware of available activities on a given day, and could affect all SB patients. The facility SB census was one.

Findings included:

1. Review of the facility's policy titled, "Admission of the Adult Patient," dated 09/11/15 directed staff to complete a patient admission assessment within eight hours of admission. The policy failed to address the provisions of patient specific activities of interest and an activity calendar for each patient.

Observation on 06/11/19 at 11:18 AM showed no activity calendar posted in Patient #2's room.

During an interview on 06/12/19 at 10:08 AM, Staff U, Licensed Practical Nurse (LPN) stated that the SB patients were invited to join the long term care residents when there were activities being done.

During an interview on 06/12/19 at 4:00 PM, Staff A, RN Director of Patient Services stated that:
- During the initial assessment, the patient likes were to be documented in the activities assessment.
- The activities director was out on sick leave since last month and they were trying to cover the activities with a Certified Nurse's Aide (CNA).
- They did not currently have any staff in place for the activities director.
- Swing bed patients were to have an activity calendar in their room.
- The patient's participation in activities were to be documented in the patient's chart.

Review of Patient #2's record showed the following:
- Staff failed to document an activity assessment.
- Staff failed to document activity participation.
- Staff failed to identify and provide activities of particular interest to Patient #2.

Review of Patient #4's discharged record showed the following:
- He was admitted on 01/17/19 for Physical and Occupational Therapy for deconditioning (physiological change following a period of inactivity or bedrest).
- Staff failed to document an activity assessment.
- Staff failed to document activity participation.
- Staff failed to identify and provide activities of particular interest to Patient #4.

Review of Patient #5's discharged record showed the following:
- He was admitted on 01/31/19 for subarachnoid hemorrhage (a life-threatening type of stroke caused by bleeding into the space surrounding the brain).
- Staff failed to document an activity assessment.
- Staff failed to document activity participation.
- Staff failed to identify and provide activities of particular interest to Patient #5.

Review of Patient #6's discharged record showed the following:
- He was admitted on 04/16/19 for generalized weakness.
- Staff failed to document an activity assessment.
- Staff failed to document activity participation.
- Staff failed to identify and provide activities of particular interest to Patient #6.

Review of Patient #7's discharged record showed the following:
- She was admitted on 04/20/19 for shortness of breath.
- Staff failed to document an activity assessment.
- Staff failed to document activity participation.
- Staff failed to identify and provide activities of particular interest to Patient #7.

Review of Patient #8's discharged medical record showed the following:
- She was admitted on 04/17/19 for Intravenous (IV, in the vein) antibiotic therapy.
- Staff failed to document an activity assessment.
- Staff failed to document activity participation.
- Staff failed to identify and provide activities of particular interest to Patient #8.

Review of Patient #9's discharged medical record showed the following:
- She was admitted on 05/21/19 for lumbar (lower back) pain requiring Physical and Occupational Therapy.
- Staff failed to document an activity assessment.
- Staff failed to document activity participation.
- Staff failed to identify and provide activities of particular interest to Patient #9.








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